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Placement Inquiry

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Acknowledgement*

Please make sure you have read and understand the contents of the MSCH Placement Information page. Answers to frequently asked questions are available on the Placement FAQs page.

I have read and understand the Placement Information and feel my child is a possible candidate for this program.

Parent/Guardian Name*

First Last

Phone*

Email*

Enter Email Confirm Email

Address*

Street Address City State / Province / Region ZIP / Postal Code

Relationship to Child*

An official copy of the custodial agreement, adoption decree, and/or guardianship paperwork is required.

How Did You Find This Inquiry Form?*

Found online

Referred by the MSCH office by phone/email

Other

Child's Information

We are unable to work with children under 12 years of age and who are under the 6th grade.

Child's Name*

First Last

Child's Age*

Please enter a number from 12 to 17.

Child's Grade*

Please enter a number from 6 to 12.

Gender*

Male

Female

Do you know your child's IQ?*

What is your child's IQ?*

Please enter a number from 1 to 180.

How does your child perform academically?*

Does your child have an IEP or 504 plan? (Please explain and provide latest report)*

Explain how your child behaves in school.*

List your child's diagnosis.*

We are unable to work with children who present on the Autistic spectrum, have Reactive Attachment Disorder, or who require high levels of medication.

List your child's medications.*

Has your child ever attempted suicide? (Please explain)*

Has your child ever been hospitalized for reasons related to suicide? (Please explain)*

Does your child self-harm? (Please explain)*

Does your child have health problems or physical restrictions? (Please explain)*

Has your child ever had a head concussion or loss of consciousness? (Please explain)*

Describe your child's "friend group"*

Describe your child's level of social skills (age-appropriate, acts younger, etc.)*

We are unable to work with children who are actively involved in gangs or who have previously participated in gang activity.

Does your child have a history of running away? (Please explain)*

We are unable to provide adequate support and safety for kids who have a history of running away.

Does your child have a desire to change and/or recognize the need to get help? (Please explain)*

List other "outside the home" placements, including the dates your child was in placement.*

How you found us?*

4 Areas of Care

“And Jesus grew in wisdom & stature, and in favor with God & man.” Luke 2:52

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Placement Inquiry

Child's Information

4 Areas of Care